Account:
Ordering Provider: Derek Shepherd, MD
Prepared: August 25, 2021 by MDR Care
Delivered: July 2021
Patient Evidence of Care
Patient Name:
Patient Date of Birth:
Patient MRN: 12345
Services Enrolled: RPM, CCM
Synced Devices: Blood Pressure
Summary
Task Summary
Tasks Status Type Scheduled Date
Care Plan Review COMPLETE on 07/28/2021 call 06/14/2021
Medication Reconciliation COMPLETE on 08/10/2021 call 08/10/2021
Notes and related tasks
Care Plan Review COMPLETE Created at: 05/31/2021 Updated at: 07/28/2021
Related Notes Date Description
Ashley, Petty, CMA 07/19/2021 1 minute Called patient for monthly health coaching call, patient
was unable to speak, call back later.
Cara, Steckert, CNA 07/28/2021 8 minutes Patient's Main discussion on Call: The patient is well and
has no concerns. We went over the Care Plan Review,
all questions answered.
Patient's Goal: Her goal is to lose weight. She is 10/10
ready to achieve this goal. Her motivation is to be a
healthier weight for her height. Vitals Being Tracked:
Weight, and Blood Pressure, and Heart Rate in RPM.
Upcoming Appointments: Orthopedic Doctor on Monday.
Cara, Steckert, CNA 07/28/2021 2 minutes Initiated Patient Health Assessment with patient during
monthly coaching call. Completed initial sections
including General Health, and Chronic Diseases. Patient
encouraged to complete remaining sections PHA through
patient portal prior to next month’s coaching call.
Medication Reconciliation COMPLETE Created at: 07/31/2021 Updated at: 08/10/2021
Clinical Care and Analysis
Sender Date Minutes Description
Marlene, Jimenez, MA 07/02/2021 2 RPM logged vitals reviewed. Current care plan appropriate for
patient at this time. No additional action needed. Will continue to
monitor patient vitals closely.
Tasks
All call, follow up, and escalation tasks Follow-ups
0
Escalations
0
Vital Tracking
Count of vitals provided by the patient either
online or over the phone Provided by patient
55
Messaging
Count of messages between a patient and
his/her care team From Patient to Care Team
0
From Care Team to Patient
9
Total Time Spent
Sum of minutes spent on care
of patient Total Minutes
48
Calls
1
Readiness for Change
Score assessed by Clinician as the patient's
readiness to make a change in their life (0-Not
ready, 5-unsure, 10-
Last 3 months
3
Current month
10
CCM Minutes
26
9 minutes of direct
messaging, 17 minutes
of clinical care and
analysis.
Engagement Score
Best score out of 5 that a patient can complete
either over the phone or online Current month
3
Out of Range
1
Alerts
Triggered when a patient logs a vital Standard
82
RPM Minutes
22
0 minutes of direct
messaging, 22 minutes
of clinical care and
analysis.
Grey Sloan Memorial Hospital
Doe, Jane
1950/01/01
Sender Date Minutes Description
Marlene, Jimenez, MA 07/08/2021 2 RPM logged vitals reviewed. Current care plan appropriate for
patient at this time. No additional action needed. Will continue to
monitor patient vitals closely.
Marlene, Jimenez, MA 07/13/2021 2 Vitals reviewed. Current care plan appropriate for patient at this
time. No additional action needed. Will continue to monitor patient
vitals closely.
Makenzie, Nimmick, CCP 07/15/2021 2 Vitals reviewed. Current care plan appropriate for patient at this
time. No additional action needed. Will continue to monitor patient
vitals closely.
Makenzie, Nimmick, CCP 07/16/2021 2 Vitals reviewed. Current care plan appropriate for patient at this
time. No additional action needed. Will continue to monitor patient
vitals closely.
Ashley, Petty, CMA 07/19/2021 4 Completed monthly pre-call review of chronic conditions,
associated goals, medication management review and
reconciliation. Reviewed demographics, problems and diagnoses,
allergies, prognosis and expected outcomes, planned interventions
and goals and care coordination.
Makenzie, Nimmick, CCP 07/23/2021 2 RPM logged vitals reviewed. Current care plan appropriate for
patient at this time. No additional action needed. Will continue to
monitor patient vitals closely.
Dailey, Avery, RN 07/27/2021 2 Vitals reviewed. Current care plan appropriate for patient at this
time. No additional action needed. Will continue to monitor patient
vitals closely.
Makenzie, Nimmick, CCP 07/28/2021 2 Vitals reviewed. Current care plan appropriate for patient at this
time. No additional action needed. Will continue to monitor patient
vitals closely.
RevUp, Nurse Group 07/30/2021 2 Patient data review with (and) triaging of critical data to delivery
RNs. Manage clinical escalations and follow-up.
Delivery, Management &
QA
07/30/2021 2 Care Team development, task management, work flow
management and skill development.
Delivery, Management &
QA
07/30/2021 2 Quality of patient care, risk analytics, adherence to protocol &
process, time spent per patient.
Marlene, Jimenez, MA 07/30/2021 2 Vitals reviewed. Current care plan appropriate for patient at this
time. No additional action needed. Will continue to monitor patient
vitals closely.
Patient Engagement Score - 3
7/1 - 7/31
Call Task Completed
Vitals logged by Clinician
Vitals logged by Patient
Session
Patient Sent Message
Patient Goal I want to lose weight
As selected by the patient during
coaching or app session Patient stated goal: lose weight
Commitment to track Weight, Activity, Meals, Medications
Staistics patient commits to
Readiness for Change 10
0-Not Ready, 5-unsure, 10-ready
4
* 3
* 2
* 1
2021-05-01 2021-06-01 2021-07-01
I+ Engagement Scores I
Patient Weight Over Past 92 Days
Patient Blood Pressure Over Past 31 Days
Patient Heart Rate Over Past 3 Months
146 - ---------------------r---------------------,----------------------r---------------------,---------------------- -
145 ~45.0 145,0
144
2021-05-15 2021-05-30 2021-06-14 2021-06-29 2021-07-14 2021-07-29
130
120
110
100
90
80
70
105
102
98
94
91
88
84
80
77
74
70
66
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I• Weight I
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1 I I I
2021-07-05 2021-07-12 2021-07-19 2021-07-26
I• Systolic ...., Diastolic I
__ J _________________ ~-----------------L ________________ J _________________ L _________________ 1 _________________ J _____ _
I I I I I I I
I I I I I ' '
I I I I I ' '
__ J _________________ ~-----------------~----------------J _________________ L _______ _ _______ _________________ J _____ _
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~- :-----------------:-----------------: ---------------- :-----------------: --------· . -------:----------------- : ------
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2021-04-30 2021-05-15 2021-05-30 2021-06-14 2021-06-29
I• Heart Rate I 2021-07-14 2021-07-29
Counts of all vitals
WEIGHT Last: Jul 28 2021, 4:24 PM 1
BLOOD PREASURE Last: Jul 31 2021, 11:58 54
PAIN TRACKING 0
MEALS LOGGED 0
STRESS 0
STEPS 0
BODY FAT 0
BLOOD SUGAR 0
SLEEP TRACKING 0
PHYSICAL ACTIVITIES 0
MOOD 0
MESSAGES SENT Last: Jul 27 2021, 12:38 PM 9
MEDICATION 0
HEART RATE Last: Jul 31 2021, 11:58 AM 54
BLOOD OXYGEN 0
BLOOD TEMPERATURE 0
Patient Direct Messaging Minutes & Topic
I• CCM: General Health I
Care Plan
PROVIDER
ACCOUNT
AGE
CCD DATE
DOB
NAME
MRN
PRIMARY LANGUAGE
CARE MANAGEMENT PROGRAM
Patient Problems
Care Management Focused Conditions:
Chronic conditions are expected to last at least 12 months, or life of the patient, and place the
patient at risk of functional decline or decompensation.
Diagnosis
Iron Deficiency
Aortic Regurgitation- Moderate
ASHD
Carotid Artery Stenosis
Colonic Polyps
Degenerative Joint Disease
Drop foot gait
Esophagitis
All known conditions:
Diagnosis
Essential (primary) hypertension
1950-01-01
Jane Doe
12345
07-30-2021
71
Grey Sloan Memorial Hospital
Derek Shepard, MD
English
RPM, CCM
Other specified peripheral vascular diseases
Diagnosis
Family History of Premature Ischemic Heart Disease
Hemangioma
Hiatal hernia
HTN, - Essen Benign
Hyperlipidemia, Mixed
Hypertensive Heart Disease
Hypothyroidism
Long Term Use Of High-Risk Medications
MGUS (monoclonal gammopathy of unknown significance)
Mitral Regurgitation
Multiple myeloma
Obesity
Osteoporosis
Patent Formen Ovale
Peripheral Vascular Disease
Thoracic Aortic Aneurysm
Tricuspid Regurgitation- Moderate
Allergies, Adverse Reactions, Alerts:
Description
Active Medications
Patient provided the following medication changes to the care team:
Crestor take 1 tablet (5 mg) by oral route once daily for 90 days - created on 04/15/2021
Vitamin D3 take 1 capsule by oral route daily - created on 04/15/2021
levothyroxine take 1 tablet (50 mcg) by oral route once daily - created on 04/15/2021
Calcium 250 MG Capsule Daily - created on 08/10/2021
NO KNOWN ALLERGIES
Reconciled date:
Medication Name Comments
250 MG Capsule, Daily Updated on 08/10/2021
iron 325 mg (65 mg iron) tablet, Takes every other
day Updated on 08/10/2021
Crestor, take 1 tablet (5 mg) by oral route once daily for
90 days Updated on 04/15/2021
levothyroxine, take 1 tablet (50 mcg) by oral route once
daily Updated on 04/15/2021
losartan, take 1 tablet (25 mg) by oral route once daily
for 90 days Updated on 04/15/2021
Vitamin D3, take 1 capsule by oral route daily Updated on 04/15/2021
08-10-2021
Patient provided the following medication changes to the care team:
iron 325 mg (65 mg iron) tablet Takes every other day - created on 08/10/2021
Goals
Clinical goals:
Goal assigned Goal statement Expected time
frame
Monitor for signs of decreased energy, hair loss,
or feeling cold, and notify your physician if they
occur.
long
04/15/2021
Exercise (aerobic physical activity such as brisk
walking) regularly, as tolerated and
recommended by your doctor. Record your
activities into your RevUp dashboard/RevUp
Health Log.
long
04/15/2021
Monitor your blood pressure daily, and record
your readings into your RevUp dashboard/RevUp
Health Log.
long
04/15/2021
Take medications regularly as prescribed. Know
how to monitor the effectiveness of your meds,
and review with your provider.
long
04/15/2021
Goal assigned Goal statement Expected time
frame
04/15/2021
Monitor for symptoms and notify provider if they
worsen:
Anxiety, irritability, or trouble sleeping
Weakness (especially in the arms and thighs,
which can make it hard to lift heavy things or
climb stairs)
Trembling
Sweating a lot and having trouble dealing with
hot weather
Fast or uneven heartbeats
Feeling tired
Weight loss even when you are eating
normally
long
04/15/2021
Adhere to a heart healthy diet (a diet that is rich
in vegetables, fruits, whole grains, and low-fat
foods). Decrease saturated fat intake. Consume
less than 200 mg of dietary cholesterol per day.
Record your meals into your RevUp
dashboard/RevUp Health Log.
long
04/15/2021
Be aware of the symptoms of thyroid storm and
seek medical attention right away if they occur:
Heart rate above 140 beats per minute
Blood pressure below 90/60 mm Hg
(Hypotension)
Temperature of 104-106 degrees Fahrenheit
Agitation, anxiety, confusion, stupor
Severe nausea, vomiting, diarrhea, abdominal
pain, and jaundice (a yellowing of the skin and
eyes)
long
04/15/2021
Maintain a healthy weight or reduce your
weight, if recommended by your physician.
Record your weight into your RevUp
dashboard/RevUp Health Log.
long
Patient goals:
Goal statement I want to lose weight
Patient stated goal lose weight
Readiness for Change 10
08/25/2021
Date Updated:
Advance Directives
Unknown
Directive Yes/No Effective Date File Name
Social History
Unavailable
Status
Care Coordination
Preventative Care
07/28/2021Date
Have you had the following in the past year?
Tobacco Use
Flu Vaccine
Have you had the following in the past 5 years?
Pneumovax
TdAP (Tetanus Shot)
Lipid Screening
Mammogram
Osteoporosis Screening
(Bone density test)
Pap Smear
Have you had the following in the past years?
Colorectal cancer screening?
Weight Measurements
Blood Pressure Measurements
Patient Weight For July, 2021
146
145 -------------------------------------------------------•-------------------------------------------------------
144
2021-07-27 11:59 PM 2021-07-28 12:00 AM
I• Weight I
130
120
110
100
90
80
70
Patient Blood Pressure For July, 2021
'
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' '
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1 I I I
2021-07-05 2021-07-12 2021-07-19 2021-07-26
I• Systolic
Diastolic I
Patient Vital Signs Report
Patient:
PCP:
Account:
RevUp Patient Type: Hybrid
Prepared August 25, 2021 by MD Revolution
Synced Devices: Blood Pressure
Jane Doe
Derek Shepard, MD
Grey Sloan Memorial Hospital
No glucose measurements available.
Glucose Measurements
Meal Logs
No meal logs available.
No fat percentage measurements available.
Fat Percent Measurements
Steps Logged
No steps logs available.
No lab results available.
Lab Results
No exercises logs available.
Exercises Logged on RevUp
Patient Heart Rate Over Past 3 Months
105 --J-----------------1-----------------~----------------J-----------------L----------------~-----------------~------
1 I I I I I I
I I I I I I I
I I I I I ' '
102 --~-----------------t-----------------~----------------~-----------------~-------- ------~-----------------t------
98
94
91
88
84
80
77
74
70
66
1 I I I I ' '
I I I I I I I
--~-----------------t-----------------~----------------~-----------------~--------· ·------~-----------------t------
' '
- - - - - - - -.- - - - - - - - - - - - - - - - - I - - - - - - - - - - -
' '
' '
--,-----------------T-----------------.-----------------,---------------
1 I I I
I I I I
2021-04-30 2021-05-15 2021-05-30 2021-06-14 2021-06-29
I• Heart Rate I 2021-07-14 2021-07-29